Imunoexpressão da proteína endonuclease apurínica/apurimidínica (APE-1) em adenomas pleomórficos e carcinomas ex-adenomas pleomórficos

Introduction: Apurinic/Apyrimidinic Endonuclease 1 (APE-1) is an essential protein for DNA base excision repair (BER) pathway and regulation of redox activities. The ability of malignant cells to recognize and repair DNA damage is an important mechanism for tumor survival, and recent studies suggest that APE-1 overexpression is related to poor prognosis in some tumors. Purpose: To analyze the immunoreactivity of APE-1 in Pleomorphic Adenomas (PA) and Carcinomas Ex Pleomorphic Adenomas (CaExPA) of salivary glands. Materials and Methods: A total of 49 tumors fixed in formalin and embedded in paraffin (33 PA and 16 CaExPA) underwent immunohistochemical study by the immunoperoxidase technique. APE-1 immunoreactivity was evaluated quantitatively by the percentage of immunopositive cells. For statistical analysis a significance level of 5% (p≤ 0.05) was adopted. Results: All cases of PA and CaExPA (n=49) were positive for APE-1, however, there was a higher expression in CaExPA, with statistically significant difference (p<0.001). There was no association between APE-1 expression and tumors of major or minor salivary gland, however, not encapsulated PA (median expression = 54.2%) showed higher expression when compared to encapsulated tumors (p=0.02). APE-1 overexpression was found mainly in cases of CaExAP with lymph node metastasis (median expression = 90.3% - p=0.002) and invasive pattern (median expression = 89.9% - p=0.003), when compared to cases without metastasis and intracapsular pattern. Conclusion: This study suggests that APE-1 is deregulated in the studied tumors. The increased expression of APE-1 is associated with the absence of complete capsule in PA and it is associated with more aggressive behavior in CaExPA.

Imunoexpressão da proteína endonuclease apurínica/apurimidínica (APE-1) em adenomas pleomórficos e carcinomas ex-adenomas pleomórficos

Introduction: Apurinic/Apyrimidinic Endonuclease 1 (APE-1) is an essential protein for DNA base excision repair (BER) pathway and regulation of redox activities. The ability of malignant cells to recognize and repair DNA damage is an important mechanism for tumor survival, and recent studies suggest that APE-1 overexpression is related to poor prognosis in some tumors. Purpose: To analyze the immunoreactivity of APE-1 in Pleomorphic Adenomas (PA) and Carcinomas Ex Pleomorphic Adenomas (CaExPA) of salivary glands. Materials and Methods: A total of 49 tumors fixed in formalin and embedded in paraffin (33 PA and 16 CaExPA) underwent immunohistochemical study by the immunoperoxidase technique. APE-1 immunoreactivity was evaluated quantitatively by the percentage of immunopositive cells. For statistical analysis a significance level of 5% (p≤ 0.05) was adopted. Results: All cases of PA and CaExPA (n=49) were positive for APE-1, however, there was a higher expression in CaExPA, with statistically significant difference (p<0.001). There was no association between APE-1 expression and tumors of major or minor salivary gland, however, not encapsulated PA (median expression = 54.2%) showed higher expression when compared to encapsulated tumors (p=0.02). APE-1 overexpression was found mainly in cases of CaExAP with lymph node metastasis (median expression = 90.3% - p=0.002) and invasive pattern (median expression = 89.9% - p=0.003), when compared to cases without metastasis and intracapsular pattern. Conclusion: This study suggests that APE-1 is deregulated in the studied tumors. The increased expression of APE-1 is associated with the absence of complete capsule in PA and it is associated with more aggressive behavior in CaExPA.

Eficiência mastigatória e qualidade das próteses totais confeccionadas pelas técnicas tradicionais e simplificada: um ensaio clínico

Traditional methods for dentures fabrication require a wide clinical and laboratory procedures; however, there is no scientific evidence that these methods can produce better results when compared with simplified methods. Aim: To evaluate the effectiveness of a simplified methods for denture fabrication, comparing it to the traditional one through masticatory efficiency and prosthesis quality. Method: A randomized controlled trial was conducted with 50 patients, 25 rehabilitated with prosthesis produced by traditional technique and 25 rehabilitated by a simplified technique. The masticatory efficiency was evaluated by colorimetric method, using chewing capsules. The quality of prosthesis was obtained using a reliable and reproducible instrument. Statistical analysis of the masticatory efficiency and quality of the prosthesis was obtained by the Mann-Whitney test. Results: 39 patients completed the study, 18 on traditional group and 21 on simplified group. There was no difference between groups for the masticatory efficiency (p = 0.835) and the quality of the prosthesis (p = 0672). The evaluation of the overall quality of the prosthesis according to oral conditions, demonstrated significant difference on the height of the mandibular ridges (p = 0.010) and mandibular muscle attachments (p = 0.039). Conclusion: Complete dentures fabricated by simplified method were considered effective from the point of view of masticatory efficiency and quality of prosthetics, with results similar to those made by the traditional method.

Eficiência mastigatória e qualidade das próteses totais confeccionadas pelas técnicas tradicionais e simplificada: um ensaio clínico

Traditional methods for dentures fabrication require a wide clinical and laboratory procedures; however, there is no scientific evidence that these methods can produce better results when compared with simplified methods. Aim: To evaluate the effectiveness of a simplified methods for denture fabrication, comparing it to the traditional one through masticatory efficiency and prosthesis quality. Method: A randomized controlled trial was conducted with 50 patients, 25 rehabilitated with prosthesis produced by traditional technique and 25 rehabilitated by a simplified technique. The masticatory efficiency was evaluated by colorimetric method, using chewing capsules. The quality of prosthesis was obtained using a reliable and reproducible instrument. Statistical analysis of the masticatory efficiency and quality of the prosthesis was obtained by the Mann-Whitney test. Results: 39 patients completed the study, 18 on traditional group and 21 on simplified group. There was no difference between groups for the masticatory efficiency (p = 0.835) and the quality of the prosthesis (p = 0672). The evaluation of the overall quality of the prosthesis according to oral conditions, demonstrated significant difference on the height of the mandibular ridges (p = 0.010) and mandibular muscle attachments (p = 0.039). Conclusion: Complete dentures fabricated by simplified method were considered effective from the point of view of masticatory efficiency and quality of prosthetics, with results similar to those made by the traditional method.

Manejo de la rinosinusitis crónica en pacientes con fibrosis quística

La rinosinusitis crónica es una patología que se presenta en pacientes con fibrosis quística y se asocia a la expresión de numerosos genes que determinan una alteración en la secreción de cloro del canal CFTR e hiperplasia de las glándulas submucosas del epitelio sinusal. En este artículo se efectúa una revisión acerca de las indicaciones y distintas alternativas de cirugía endoscópica nasal para la rinosinusitis crónica en pacientes con fibrosis quística. Se realizó una búsqueda de artículos en PubMed, la biblioteca de Cochrane y en SciELO con fecha de publicación hasta el año 2014, en los que se trata específicamente la rinosinusitis crónica asociada a fibrosis quística.

Sinusite maxilar odontogénica

O seio maxilar é o seio paranasal mais susceptível a invasões bacterianas, tanto pelo óstio nasal, como pela cavidade oral. As sinusites maxilares têm como causas mais frequentes, as infecções víricas, rinites alérgicas ou não alérgicas, variações anatómicas, diabetes mellitus, fumar, nadar, mergulhar, escalar a altas atitudes, e as infecções e tratamentos dentários. A pesquisa bibliográfica, foi realizada sem quaisquer limitações temporais, com restrição linguística a Português, Espanhol e Inglês, sendo excluídos os artigos de outros idiomas; em vários livros e revistas, assim como artigos científicos obtidos, entre Maio e Julho de 2015, nos motores de busca Pubmed, ScienceDirect, Scielo, Elsevier e B-on. A sinusite maxilar odontogénica é uma doença infecto-inflamatória, habitualmente associada à ruptura da membrana de Schneider e a processos infecciosos dentários crónicos. Causa hiperplasia e hipertrofia da mucosa, o que origina sinais e sintomas próprios, assim como mudanças radiográficas perceptíveis. Existem diferentes etiologias de causa odontogénica: cárie, doença periodontal, quistos odontogénicos e iatrogenia – tratamento endodôntico não cirúrgico, cirurgia endodôntica, comunicações oro-antrais, implantes dentários, elevação do seio maxilar, cirurgia pré-protética e cirurgia ortognática – sendo que a iatrogenia é a mais comum (cerca de 56%). Esta patologia afecta com mais frequência indivíduos dos 42,7 aos 51, 7 anos, e preferencialmente a região molar, seguida dos pré-molares e em alguns casos, caninos. Os organismos que dominam na fase aguda e crónica, são sensivelmente os mesmos, mas em número diferente, e existe uma conexão entre a flora comensal periapical e a flora patogénica em caso de sinusite maxilar odontogénica. O diagnóstico é essencialmente clínico, no entanto existem diferentes exames complementares para confirmarem ou formarem o diagnóstico. Pela grande acessibilidade ao método radiográfico, torna-se fundamental que o médico dentista saiba diferencial as diversas patologias que afectam o seio maxilar. O tratamento abrange a eliminação da causa dentária e o tratamento farmacológico, da infecção, essencialmente à base de antibióticos, e da dor se esta existir. E o tratamento cirúrgico, que contempla a punção-lavagem sinusal, antrostomia intranasal, técnica de Caldwell-Luc e cirurgia sinusal endoscópica. Concluindo, o médico dentista deve ter um amplo conhecimento sobre esta patologia para que a possa reconhecer, tratar ou preveni-la.

Serum copper evolution in patients that underwent endoscopic gastrostomy for long term enteral feeding

Background and aims: Copper (Cu) is a well studied trace element but little is known about Cu evolution in long term endoscopic gastrostomy (PEG) feeding. We aimed to evaluate the evolution serum Cu since the gastrostomy until 12 weeks after the procedure in PEG patients fed with homemade meals. Methods: A prospective observational study was performed evaluating serum copper, albumin, transferrin and body mass index (BMI) at the time of the gastrostomy, 4 weeks and 12 weeks after. Data also included age, gender, NRS 2002 and nature of the underlying disease causing dysphagia: head and neck cancer (HNC) or neurological dysphagia (ND). After gastrostomy, patients were fed with homemade PEG meals. Results: One hundred and forty-six patients enrolled, 89 men, aged 21-95 years, 90 with neurologic dysphagia (ND), and 56 with head and neck cancer (HNC). 78 (53%) showed low BMI. Initially, Cu ranged 42-160 μg/dl (normal: 70-140 μg/dl); 130 patients (89%) presented normal Cu, 16 (11%) presented hypocupremia, 53% low albumin (n = 77), and 94 (65%) low transferrin. After 4 weeks, 93% presented normal Cu, 7% presented hypocupremia, low albumin was present in 34%, and low transferrin in 52%. After 12 weeks, 95% presented normal Cu, 5% presented hypocupremia, low albumin was present in 25%, and low transferrin in 32%. Comparing age, gender, underlying disease, BMI, albumin and transferrin, there were no significant differences on serum Cu. Conclusions: Most patients present normal serum Cu when gastrostomy is performed. For patients presenting hypocupremia before gastrostomy, homemade meals are effective for normalizing serum Cu.

Selenium in dysphagic patients who underwent endoscopic gastrostomy for long term enteral feeding

Background and aims - Endoscopic gastrostomy (PEG) patients usually present protein-energy malnutrition, but little is known about selenium deficiency. We aimed to assess serum selenium evolution when patients underwent PEG, after 4 and 12 weeks. We also evaluated the evolution of albumin, transferrin and Body Mass Index and the influence of the nature of the underlying disease. Methods - A blood sample was obtained before PEG (T0), after 4 (T1) and 12 (T3) weeks. Selenium was assayed using GFAAS (Furnace Atomic Absorption Spectroscopy). The PEG patients were fed through homemade meals. Patients were studied as a whole and divided into two groups: head and neck cancer (HNC) and neurological dysphagia (ND). Results - We assessed 146 patients (89 males), between 21-95 years old: HNC-56; ND-90. Normal values of selenium in 79% (n=115); low albumin in 77, low transferrin in 94, low values for both serum proteins in 66. Low BMI in 78. Selenium has slow evolution, with most patients still displaying normal Selenium at T3 (82%). Serum protein levels increase from T0 to T3, most patients reaching normal values. The nature of the underlying disease is associated with serum proteins but not with selenium. Conclusions - Low serum selenium is uncommon when PEG is performed, after 4 and 12 weeks of enteral feeding and cannot be related with serum proteins levels or dysphagia cause. Enteral nutrition using customized homemade kitchen meals is satisfactory to prevent or correct Selenium deficiency in the majority of PEG patients.

Sistema de realidade aumentada no procedimento cirúrgico de remoção de pedras nos rins

A inovação tecnológica e as facilidades que gera tem tido um impacto crescente em diversas área, inclusivamente na medicina. A rápida evolução por parte de algumas tecnologias, como é o caso da Realidade Aumentada (RA), criam excelentes oportunidades, nomeadamente para intervenções cirúrgicas laparoscópicas, que apresentam especialmente problemas ao nível da exposição do doente a radiação. O presente documento detalha todo o processo de investigação e desenvolvimento realizado com a pretensão de criar um sistema de navegação por RA que auxilie o procedimento cirúrgico laparoscópico de remoção de pedras nos rins. Com este objetivo em perspetiva, e numa parceria com a empresa ECmedica LTD, foram desenvolvidos quatro protótipo funcionais. Com o intuito de compreender as melhores práticas de sistemas de input, interface e sistema de registo a aplicar, estes integraram aspetos inovadores tais como a utilização de uma sonda ultra-som, como substituta do raioX, e um registo feito através de sensores magnéticos. Apoiados numa metodologia de design centrado no utilizador e em instrumentos de análise como entrevistas e observação natural, os protótipos foram testados, obtendo respostas esclarecedoras relativamente ao objetivos dos protótipos. Foi observado que a RA é vista pelos médicos como uma solução com potencial, com as soluções apresentadas ao nível de inputs, interface e registo a serem bem recebidas. A projeção bidimensional oferecida pela imagem ultra-som foi encarada como insuficientes, sendo sugerida a sua substituição por um aumento tridimensional capaz de facilitar a correta inserção da agulha.

Endoscopic treatment of bleeding gastric varices with histoacryl (N-butyl-2-cyanoacrylate): a South European single center experience

BACKGROUND: Endoscopic injection of N-butyl-2-cyanoacrylate is the current recommended treatment for gastric variceal bleeding. Despite the extensive worldwide use, there are still differences related to the technique, safety, and long term-results. We retrospectively evaluated the efficacy and safety of cyanoacrylate in patients with gastric variceal bleeding. PATIENTS AND METHODS: Between January 1998 and January 2010, 97 patients with gastric variceal bleeding underwent endoscopic treatment with a mixture of N-butyl-2-cyanoacrylate and Lipiodol(TM). Ninety-one patients had cirrhosis and 6 had non-cirrhotic portal hypertension. Child-Pugh score at presentation for cirrhotic patients was A-12.1 %; B-53.8 %; C-34.1 % and median MELD score at admission was 13 (3-26). Successful hemostasis, rebleeding rate and complications were reviewed. Median time of follow up was 19 months (0.5-126). RESULTS: A median mixture volume of 1.5 mL (0.6 to 5 mL), in 1 to 8 injections, was used, with immediate hemostasis rate of 95.9 % and early rebleeding rate of 14.4 %. One or more complications occurred in 17.5 % and were associated with the use of Sengstaken-Blakemore tube before cyanoacrylate and very early rebleeding (p < 0.05). Hospital mortality rate during initial bleeding episode was 9.3 %. Very early rebleeding was a strong and independent predictor for in-hospital mortality (p < 0.001). Long-term mortality rate was 58.8 %, in most of the cases secondary to hepatic failure. CONCLUSION: N-butyl-2-cyanoacrylate is a rapid, easy and highly effective modality for immediate hemostasis of gastric variceal bleeding with an acceptable rebleeding rate. Patients with very early rebleeding are at higher risk of death.

Is there still a role for intraoperative enteroscopy in patients with obscure gastrointestinal bleeding?

BACKGROUND: in 21st century, endoscopic study of the small intestine has undergone a revolution with capsule endoscopy and balloon-assisted enteroscopy. The difficulties and morbidity associated with intraoperative enteroscopy, the gold-standard in the 20th century, made this technique to be relegated to a second level. AIMS: evaluate the actual role and assess the diagnostic and therapeutic value of intraoperative enteroscopy in patients with obscure gastrointestinal bleeding. PATIENTS AND METHODS: we conducted a retrospective study of 19 patients (11 males; mean age: 66.5 ± 15.3 years) submitted to 21 IOE procedures for obscure GI bleeding. Capsule endoscopy and double balloon enteroscopy had been performed in 10 and 5 patients, respectively. RESULTS: with intraoperative enteroscopy a small bowel bleeding lesion was identified in 79% of patients and a gastrointestinal bleeding lesion in 94%. Small bowel findings included: angiodysplasia (n = 6), ulcers (n = 4), small bowel Dieulafoy´s lesion (n = 2), bleeding from anastomotic vessels (n = 1), multiple cavernous hemangiomas (n = 1) and bleeding ectopic jejunal varices (n = 1). Agreement between capsule endoscopy and intraoperative enteroscopy was 70%. Endoscopic and/or surgical treatment was used in 77.8% of the patients with a positive finding on intraoperative enteroscopy, with a rebleeding rate of 21.4% in a mean 21-month follow-up period. Procedure-related mortality and postoperative complications have been 5 and 21%, respectively. CONCLUSIONS: intraoperative enteroscopy remains a valuable tool in selected patients with obscure GI bleeding, achieving a high diagnostic yield and allowing an endoscopic and/or surgical treatment in most of them. However, as an invasive procedure with relevant mortality and morbidity, a precise indication for its use is indispensable.

Capsule endoscopy in inflammatory bowel disease type unclassified and indeterminate colitis serologically negative

BACKGROUND: The value of capsule endoscopy in the setting of inflammatory bowel disease type unclassified (IBDU) and indeterminate colitis (IC) remains obscure. The aim was to evaluate the clinical impact of capsule endoscopy on IBDU/IC patients with negative serology. METHODS: Eighteen patients with long-standing IBDU (n = 14) and IC (n = 4) were enrolled to undergo a capsule endoscopy and then followed prospectively. Lesions considered diagnostic of Crohn's disease (CD) were 4 or more erosions/ulcers and/or a stricture. The median follow-up time after capsule endoscopy was 32 ± 11 months (23-54 months). RESULTS: Total enteroscopy was possible in all patients. In 2 patients the examination was normal (Group 1). In 9 patients subtle findings were observed (Group 2): focal villi denudation (n = 1) and fewer than 4 erosions/ulcers (n = 8). In 7 patients, 4 or more erosions/ulcers were detected (Group 3), leading to a diagnosis of CD. However, their treatment was not reassessed on the basis of the capsule findings. Until now, a definitive diagnosis has been achieved in 2 additional patients: 1 from Group 1 (ulcerative colitis) and another patient from Group 2 (CD), who began infliximab infusions. Nine patients remained indeterminate at follow-up. CONCLUSIONS: Although capsule endoscopy enabled the diagnosis of CD in 7 patients, in none of them was the clinical management changed. Moreover, a change in therapy due to a diagnosis of CD was made for only 1 patient, who presented nonspecific findings. Our results suggest that capsule findings are not helpful in the work-up of these patients

Urgent capsule endoscopy is useful in severe obscure-overt gastrointestinal bleeding

AIM: With capsule endoscopy (CE) it is possible to examine the entire small bowel. The present study assessed the diagnostic yield of CE in severe obscure-overt gastrointestinal bleeding (OOGIB). METHODS: During a 3-year period, 15 capsule examinations (4.5% of all CE in a single institution) were carried out in 15 patients (11 men; mean age 69.9 +/- 20.1 years) with severe ongoing bleeding, defined as persistent melena and/or hematochezia, with hemodynamic instability and the need for significant red blood cell transfusion. CE was carried out after non-diagnostic standard upper and lower endoscopy. The mean time from admission until CE was 4.1 +/- 4.4 days (0-15 days). RESULTS: CE revealed active bleeding in seven patients and signs of recent bleeding in four. Etiology of bleeding was correctly diagnosed in 11 patients (73.3%) (portal hypertension enteropathy, three patients; subepithelial ulcerated lesion, two patients; angiodysplasia, two patients; jejunal ulcer with visible vessel, one patient; multiple small bowel ulcers, one patient; jejunal tumor, one patient; jejunal mucosa irregularity with adherent clot, one patient). One patient (6.7%) had active bleeding but no visible lesion. As a consequence of the capsule findings, specific therapeutic measures were undertaken in 11 patients (73.3%) with five managed conservatively, four endoscopically and two surgically. Two patients experienced bleeding recurrence. One of them, with a probable small bowel tumor, refused any other interventions. CONCLUSIONS: CE is useful in patients with severe OOGIB by providing positive findings in the majority of patients, with subsequent impact on therapeutic procedures.

The effect of metoclopramide in capsule enteroscopy

Clinical utility of prokinetics in capsule endoscopy (CE) is not clearly established. The objective of this prospective, randomized, single-blind, controlled trial was to determine if metoclopramide is useful in CE by increasing the rate of complete enteroscopy. Ninety-five patients referred for CE were randomized to no metoclopramide (group B, n = 48) or 10 mg metoclopramide (group A, n = 47). Complete enteroscopy was possible in 38 patients of group A (80.9%) and 37 of group B (77.1%) (P = 0.422) with two cases of gastric retention in group B (4.2%; P = 0.253). Median gastric transit time was 26 min (1-211) in group A and 28 min (4-200) in group B (P = 0.511). Mean small bowel transit time, calculated after excluding 20 patients with incomplete enteroscopy, was similar in both groups (221.2 +/- 89 min vs. 256 +/- 82.2 min; P = 0.083). There were also no differences in the total number of findings (group A 4.5 +/- 4.7; group B 4.7 +/- 3.7, P = 0.815). Administration of 10 mg metoclopramide orally 15 min before capsule ingestion did not significantly increase the rate of total enteroscopies and had no effect on transit times. It also did not modify CE diagnostic yield.

Effect of portal hypertension in the small bowel: an endoscopic approach

BACKGROUND AND AIM: The effects of portal hypertension in the small bowel are largely unknown. The aim of the study was to prospectively assess portal hypertension manifestations in the small bowel. METHODS: We compared, by performing enteroscopy with capsule endoscopy, the endoscopic findings of 36 patients with portal hypertension, 25 cirrhotic and 11 non-cirrhotic, with 30 controls. RESULTS: Varices, defined as distended, tortuous, or saccular veins, and areas of mucosa with a reticulate pattern were significantly more frequent in patients with PTH. These two findings were detected in 26 of the 66 patients (39%), 25 from the group with PTH (69%) and one from the control group (3%) (P < 0.0001). Among the 25 patients with PTH exhibiting these patterns, 17 were cirrhotic and 8 were non-cirrhotic (P = 0.551). The presence of these endoscopic changes was not related to age, gender, presence of cirrhosis, esophageal or gastric varices, portal hypertensive gastropathy, portal hypertensive colopathy, prior esophageal endoscopic treatment, current administration of beta-blockers, or Child-Pugh Class C. More patients with these endoscopic patterns had a previous history of acute digestive bleeding (72% vs. 36%) (P = 0.05). Active bleeding was found in two patients (5.5%). CONCLUSIONS: The presence of varices or areas of mucosa with a reticulate pattern are manifestations of portal hypertension in the small bowel, found in both cirrhotic and non-cirrhotic patients. The clinical implications of these findings, as regards digestive bleeding, are uncertain, although we documented acute bleeding from the small bowel in two patients (5.5%).